From the ominously-titled book, “New Rules,” by Donald Berwick MD and Troyen Brennan MD:
“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care…is to constrain decentralized individualized decision making.”
Unfortunately, Dr. Berwick’s straightforward formulation of the appropriate role of the individual physician in our reformed healthcare system is not isolated to thinkers of the Progressive persuasion. The notion that most clinical decisions can be usefully made by a centralized authority is attractive even to some conservatives.
For example, a few years ago the noted economist Arnold Kling strongly defended the idea. “My own view is that a remote third party probably can use statistical evidence to make good recommendations for a course of treatment.”
Now, Kling is no far-left radical, pushing for centralized control of healthcare (and everything else). Indeed, he is now with the Cato Institute, and before that he taught economics at George Mason University. So he has earned his conservative and/or libertarian chops.
And to be fair, he is not really calling here for “remote third parties” to have final authority on what’s best for individual patients. Rather, he thinks patients should make that decision for themselves, weighing the recommendations of data-driven guidelines promulgated by remote experts, against the ego-toss’d recommendations from their all-too-fallible doctors, or, as Kling sarcastically refers to them, their “heroic personal saviors.” (Such sarcasm, regular readers will know, is as abhorrent to DrRich as it probably is to you.) Kling is saying: trust patients, armed with good evidence-based recommendations handed down from experts, to make the right decisions for themselves.
In concept even DrRich supports this latter notion. Indeed, a chief theme of this blog has been that doctors have been coerced into such a compromised position by the government and the insurance carriers that wise patients will no longer simply trust their doctors’ advice explicitly. As things now stand, patients who place full reliance on their doctors, assuming that they’ll get all the information they need to make good medical decisions, are putting themselves in peril. Smart patients will seek out all the information they can about their own medical conditions, so they can confirm that their doctors are indeed presenting them with all their reasonable options, and so they can more intelligently evaluate those options. And certainly, expert-endorsed guidelines would be an important part of that research.
But Kling’s remedy – that patients rely on the treatment recommendations made by expert panels as a remedy to the conflicted advice being doled out by their own doctors – is seriously flawed.
The first flaw, of course, is the idea that remote third parties, wielding evidence-based data, can make good treatment recommendations for individual patients. Evidence-based guidelines, almost by definition, are designed to improve the average outcome across a population of individuals, and are specifically designed not to optimize outcomes for each individual within that population.
Second, Kling apparently assumes that the remote third parties who are producing evidence-based treatment recommendations will be acting in a completely objective and unbiased manner. But this can never be the case. A major theme of the Covert Rationing Blog this past year has been to demonstrate that a) clinical science is probably the least exact of the sciences; b) the design and interpretation of clinical studies is inevitably attended by significant bias; and c) therefore, no matter who is producing them – whether it is medical professionals or GOD panelists (Government Operatives Deliberating) – these guidelines will always be produced with a particular agenda in mind. To assume that such agendas will be primarily – or even remotely – related to optimizing the outcomes of individual patients will often be a serious error.
Third, the idea that patients, even very intelligent patients armed with “perfect information,” can by themselves reliably sort through the morass of conflicting evidence and conflicting opinions that invariably inform any set of clinical recommendations (whether made by vaunted teams of completely objective experts from on-high, or by one’s inherently flawed, conflicted and ego-driven personal physician) is simply false. This would be the case even if the healthcare system were perfectly aligned to help patients. Which, of course, it is not. (It is aligned to affect the covert rationing of healthcare.)
Finally, while the advice patients get from their doctors is indeed biased, more and more it is biased (thanks to heavy-handed coercion) in favor of those same central authorities that are commissioning the expert panels.
As a result, patients – especially when they are sick and least able to fend for themselves – are generally incapable of negotiating the gratuitous complexities and hidden hazards laid out before them by a hostile healthcare system, a system which silently prays they will, in frustration, just go buy themselves some alternative medicine remedy, then crawl under a bush and die while contemplating their qi. Indeed, patients are as incapable of successfully navigating such a system as are accused felons of navigating a complex and hostile legal system that’s bent on sending them away for 15-20 years.
It is for this very reason that accused felons are assigned an advocate, an individual who is ethically and legally obligated to take their part, to help them navigate all the legal hazards, to do everything possible to see they are treated fairly, and that they are given every reasonable chance to prove their innocence. Lawyers, as much as we physicians might like to castigate them, are absolutely critical to a civil society.
And this is the reason why patients (according to traditional, though now quaint, medical ethics) are also supposed to have a personal advocate, an individual who is obligated to take their part, to help them navigate all the medical hazards, to do everything possible to see that they are treated fairly and that all available medical options are made open to them, and that they are given every reasonable chance of a good clinical outcome. Patients, in other words, need doctors who are devoted to the classic precepts of their profession. Such doctors, as much as Kling and others might like to diminish their importance, are also absolutely critical to a civil society.
But, as we have seen, and as has been publicly celebrated by Dr. Berwick and others, severing the classic doctor-patient relationship has been Job One under our system of covert rationing – whether that rationing is managed by insurance companies or by the government. Doctors simply cannot be allowed any longer to place their patients first. They’ve got to place the needs of their true masters first. They’ve got to keep the government and the insurers happy or they’re out of a job. They are no longer permitted to tailor clinical choices to best fit their individual patients, but they are simply to apply treatment directives as they are handed down by (from now on, government-appointed) panels of experts.
And this brings us back to Kling. DrRich of course agrees with his notion that patients ought to be armed with the high-quality information they need to determine their own medical destiny. DrRich can even agree that relying solely on the information provided by today’s doctor is generally not advisable. But DrRich cannot agree with the reason it’s not advisable. Doctors aren’t so much inherently flawed by ego and other intrinsic character flaws (at least, no more than any other group of humans), as they are operating under duress, under imposed constraints, and under external coercions that systematically and purposefully prevent them from discharging their professional obligations.
Nor can DrRich agree with Kling’s proposed solution. No centralized set of recommendations, evidence-based or not, can fix this problem for patients – especially when the expert bodies that make those recommendations are controlled by the same entities that have, with malice aforethought, killed the medical profession for the express purpose of stripping patients of their advocates, and therefore, of their medical options.
DrRich has trouble seeing a solution to this problem that is not radical. He does not see how doctors can resume their rightful place as their patients’ advocates and remain in what has become of the traditional healthcare system. Perhaps enough doctors to make a difference will leave the traditional healthcare system, shedding themselves of the third parties who now control their behavior, and re-establishing their practices (and revitalizing their profession) with a new commitment to the doctor-patient relationship. If not, then perhaps some brand new profession will establish itself (call it “personal healthcare advocates”) to fill the great void that threatens the safety of every American patient.
So yes, let individual patients weigh all the evidence and choose the healthcare option that suits them best. But unless they have a personal advocate to help them navigate the morass of biased choices – whether that advocate is their PCP like it’s supposed to be, or some new variety of professional advocate – those options will be limited to whatever healthcare is deemed best by the central planners.
A fine economist such as Dr. Kling should realize that a remote third party can no more make good recommendations for individual patients trying to survive in the rough and tumble of the healthcare system, than can a remote third party make good recommendations for individual businesses trying to compete in the rough and tumble of the marketplace. It is one thing for Progressives to hold to such a notion. It is far more disturbing to see respected conservative thinkers doing so.
It should by now be obvious to everyone that, in its great push to take over the American healthcare system, our government will do everything it must to eliminate private practice physicians. This is necessary because Obamacare (or any government-controlled healthcare system) simply cannot operate unless physicians cooperate completely with the Central Authority. Physician behavior absolutely must be controlled, and so doctors who insist on acting independently must either be reeducated or eliminated.
(Don’t get too exercised about DrRich’s language here – he is talking mainly about forcing recalcitrants into early retirement, or career changes. The other kind of “elimination” probably will not become necessary.)
Accordingly, under Obamacare all doctors are to be driven into federally-sanctioned organizations that will operate strictly under government directives. The current parlance for such an organization is the “Accountable Care Organization.”
The ACOs will be run by administrators who (theoretically) will become expert at navigating the morass of rules and regulations now being conjured up under Obamacare. These administrators will interpret the rules and regulations in such a way as to determine The Way It Must Be Done, and then will pass The Way It Must Be Done down to the ACOs’ clinical chiefs (doctors who perhaps used to practice medicine, and maybe still do, a little, but who are now mainly brevet administrators), and the clinical chiefs will finally pass the restrictive rules of engagement down to the doctors who will actually take care of the patients. These doctors, struggling in the trenches, will attempt assiduously to follow those rules without exception, if they would like to keep their jobs as well as avoid a federal fraud rap. The patients, of course, will get whatever they get, but always with official assurances that whatever it is they get, it will be of the highest quality.
As DrRich has pointed out, doctors have very little leverage under this kind of system. Not only do they have the full weight of the federal government pushing them toward their fate as functionaries within ACOs, but they also are being pushed to so assimilate by their own professional organizations. Indeed, thanks to the New Age medical ethics which their professional organizations have promulgated on their behalf, joining collectives such as ACOs is about to become the only ethical way of practicing medicine. (DrRich has shown that this is explicitly so, and that Dr. Berwick agrees.) Doctors who try to make a go of it on their own will not only be practicing extra-legally, but also extra-ethically.
So this is where we are headed.
But we’re not there yet. Far too many physicians are still fundamentally independent-minded; there is still a lot of work to be done to get all the doctors to assimilate into the Borg.
And a major step in this direction will be to eliminate Independent Practice Associations. While the systematic emasculation of IPAs has been going on for years, it is to accelerate rapidly under Obamacare.
IPAs are groups of doctors who own independent medical practices, and who join together to provide bulk services to health insurers at rates of payment that are negotiated collectively. IPAs have a long and respected history for over a half-century. But they have been on the Fed’s hit list since at least the Clinton administration.
The rules under which IPAs must operate in legally negotiating with insurance companies have become complex, illogical, restrictive, arbitrary and ultimately ironic. The full weight of the federal government has been brought to bear against IPAs, apparently to protect the large and powerful health insurance companies, not to mention government health insurers, against “price fixing” by independent doctors – while simultaneously imposing price fixing by those same insurers upon the IPA physicians .
So: not only is it a violation of anti-trust for two random doctors to have a cup of coffee and mention anything to each other about their respective reimbursement rates, it is also illegal for fellow members of an IPA (who are joined together in collective bargaining with insurers) to do so. Indeed, the only kind of negotiation that is apparently allowed (“apparently” because the actual rules are not explicit but implied, and change arbitrarily depending on which administrators are running the Federal Trade Commission) is called the “messenger model” of negotiation. The messenger model is necessitated by the fact that physician members of the IPA are not allowed to communicate with each other about rates, so each IPA must hire a “negotiator” who communicates between individual physician IPA members and the insurer. Furthermore, physicians are not allowed to declare to the insurer what level of reimbursement they will accept (because that would be price fixing), but rather, they can only hear the proposed reimbursement rates from the insurer, and accept or reject them. And in recent years, rejecting the offer by insurers, especially government insurers, has sometimes been determined also to be physician price fixing. This system, for reasons unfathomable to DrRich, is NOT to be considered price fixing on the part of the insurers.
DrRich is not sure he has this entirely right, because it is far more complex than he has allowed, and indeed, the rules are manifestly changeable and unclear, even to professional IPA negotiators.
In fact, it has proven to be very easy (and progressively easier as the years have gone by) for IPAs to get into serious trouble with the FTC, and incur massive fines, for “violations” that are not only fundamentally harmless to any party, but that had been perfectly acceptable behaviors in the recent past. To get the full flavor of the runaway prosecutorial zeal with which the FTC has been acting against IPAs, DrRich strongly recommends that you read this article in the December Reason Magazine by S. M. Oliva. (Many thanks to concerned reader Robert R. for pointing DrRich to this article.)
When the FTC decides to prosecute an IPA for price fixing or other violations-du-jour of the negotiating process, the IPA’s only reasonable course of action is to cave in immediately, sign a consent decree, pay the always-huge and always-arbitrary fine, and then abjectly accept whatever reimbursement rates the insurance company is willing to pay. This resolution to federal charges is unattractive, but at least it gives the IPA some chance of continued survival.
And if you don’t like the terms of the consent decree being imposed upon you, for God’s sake keep your mouth shut about it. When the director of a Colorado IPA recently told the press that her organization had done nothing materially wrong, but had signed the consent decree because they simply could not afford to fight the FTC in court (a truism for any IPA), the FTC sanctioned her as an individual, and barred her from negotiating with insurance companies for two years (effectively ending her career, simply for exercising her right of free speech). Even one of the FTC’s own commissioners, in a dissenting opinion, agreed that this latter action had been a travesty. (It was carried out nonetheless).
And so, operating a medical practice in an IPA has been a pretty dicey thing for several years now.
But Obamacare escalates the risk to a whole new level.
While dealing with the FTC is itself a decidedly nasty proposition, it’s nothing compared to dealing with the Justice Department. And Obamacare brings the DOJ into the fight to eliminate “price fixing” by doctors. That is, a violation of arbitrary and unpredictably changeable rules during IPA negotiations is not just a civil matter anymore, but is potentially (at the discretion of the Feds) a criminal matter.
It looks more and more like the handwriting is on the wall for IPAs, or for any independent, private practice physician who wants to take care of insured patients.
So, once again, DrRich begs his physician friends to consider the alternatives. Think about getting out now, dropping out of the system altogether while you still can, and establishing a direct-pay practice before that, too, is rendered illegal. The window of opportunity is closing.
And, sadly, you may want to re-read DrRich’s helpful suggestions regarding black market healthcare, as that may become the only viable alternative to the Borg – and much sooner than DrRich had previously thought.
In early 2010, The Covert Rationing Blog and the ACP Advocate Blog were named finalists in the 2009 Medical Weblog Award Competition, in the category of Best Health Policy/Ethics Blog. DrRich, who has been a vocal critic of the “New Ethics” espoused by the ACP (and other professional organizations), took the opportunity to challenge the ACP to a public debate on medical ethics.
The ACP initially accepted the challenge, but quickly withdrew from the field. Nonetheless, several entertaining posts resulted. If nothing else, the following posts clearly outline the glaring deficiencies of the medical professions’ “New Ethics.”
Part 1 – DrRich Issues A Challenge To the ACP: Since the Weblog Awards have seen fit to throw us together in a formal “contest” about medical ethics, let’s take this opportunity (for the sake of the voters) to debate the following proposition: The New Ethics promoted by the ACP is harmful to patients, and destroys the ethical underpinning of the medical profession.
Part 2 – DrRich Renews the Challenge: While the ACP cogitated on whether their new Weblog Awards finalist status obligated them, the mighty ACP, to respond to DrRich (best known as some guy in the blogosphere), DrRich revealed for them the Right Way to think about medical ethics.
Part 3 – The ACP Issues a Formal Response, and DrRich Rebuts: The Chair of the ACP Ethics, Professionalism and Human Rights Committee responds, and informs DrRich that he makes much ado about nothing. DrRich offers a devastating rebuttal that, in the end, proves to be dispositive.
Part 4 – Further Goading By DrRich: Attempting to entice the ACP to respond to his rebuttal, DrRich becomes just a touch less polite, by offering a commentary on the ACP’s astounding exhortation that physicians practice “parsimonious care.”
Part 5 – Advice to Primary Care Physicians Who Labor Under the “New Ethics:” Having demonstrated the fundamental bankruptcy of the New Ethics, and the inability (or unwillingness) of their professional organization to respond to a reasoned challenge, DrRich offers some advice to the very physicians who are expected to work under these untenable ethical precepts.
Part 6 – Taking the Loss Philosophically: While considering himself to have won the Great Medical Ethics Smack Down (by default, if nothing else), DrRich graciously congratulates the ACP for their astounding, stroke-of-midnight victory in the Weblog Awards.
Thanks to Ms. Wood of the Occam Practice Management Blog for calling DrRich’s attention to an interesting article appearing recently in the Wall Street Journal Health Blog. This article describes the efforts of a non-profit organization called the Investor Protection Trust to (it appears) medicalize the problem of financial scams involving the elderly.
Specifically, under the auspices of the IPT, government securities regulators will be teaming up with physicians organizations (in particular, the American College of Physicians and the American Academy of Family Physicians), to train PCPs to recognize signs that their elderly patients are victims of financial fraud or exploitation. If such fraud is uncovered or suspected, the physician is to notify Adult Protective Services, an organization which (helpfully) is not subject to certain annoying confidentiality regulations. IPT estimates that screening for financial abuse can be accomplished by adequately-trained PCPs in only three short minutes.
The plan is to have PCPs take special training to help them recognize the signs of financial elder abuse. This training can be accomplished in only two hours, the IPT explains, and will be conducted “under the auspices of medical ethics continuing education.”
Long-time readers will know that DrRich is the President (and sole member) of Future Old Farts of America. (He retains this position despite the fact that his eligibility for FOFA is rapidly expiring, and, some have suggested, has already expired.) As President of FOFA, DrRich naturally deplores financial fraud perpetrated upon the elderly. Indeed, this is one of the chief reasons he opposes Obamacare.
So DrRich applauds this new effort to protect the fiscal wholeness of our beloved elderly. The plan is flawless, as it has something good in it for everyone – except, perhaps, the PCPs.
The IPT itself stands to gain much from this new program, since this organization is funded through fines collected from investment-fraud cases. Having American PCPs embark on a major, sustained, grass-roots effort to troll for such investment fraud (using screening criteria developed by the IPT itself) should greatly increase this organization’s revenue.
The major physicians organizations which represent PCPs – the ACP and the AAFP – also come out ahead by supporting this effort. They reap, of course, all the public relations benefits that always go along with new programs aimed at assisting our esteemed elderly population. But perhaps more importantly, their participation in this program helps them with the small “ethics problem” they have lately created for themselves.
As regular readers will know, the ACP and AAFP are major proponents – and indeed the authors – of the New Age medical ethics that was formally adopted by the medical profession in 2002. This new ethics, as DrRich has patiently explained, obligates physicians to strive to practice medicine for the benefit of the collective. Practically speaking, the “new ethics” creates the ethical foundation by which American physicians will practice medicine according to fiats handed down by government-controlled expert panels. That is, it excuses physicians from their now-obsolete obligation to always do what’s best for the individual patient, in favor of doing what’s best for society as a whole, as determined at a distance by the Central Authority.
All well and good. As DrRich has amply demonstrated, the ACP (at least) is quite satisfied with its new medical ethics, and sees no reason to reconsider. But still, this creates a problem for the ACP when it comes to “medical ethics continuing education.” Thoughtful physicians, when faced with indoctrination programs aimed at getting them to absorb the new medical ethics, often raise uncomfortable questions, questions which (as, again, DrRich has shown) even the chairperson of the ACPs’s ethics committee cannot effectively answer. Clearly then, having formally tossed real medical ethics aside has undoubtedly made these ethics sessions somewhat awkward for the instructors.
What better solution to this embarrassing problem than distraction? Simply turn these annoying continuing education sessions into something other than a discussion of medical ethics. Turn it into, say, a two-hour session on recognizing financial fraud among the elderly. You’ve got to have something to talk about, after all – and defrauding the elderly is unethical, is it not? It is not hard to understand why physicians organizations are so supportive of the IPT’s new effort.
But, of course, the very first among the beneficiaries of the medicalization of elder fraud is the government.
Most directly, anything that helps to keep the estates of the (pleasantly) befuddled elderly intact, until they pass on to their more permanent rewards, will increase revenues to the state and federal governments through inheritance taxes.*
*DrRich leaves it to the reader to decide whether the benefits to the overall economy are greater if the accumulated wealth of the elderly is passed on to the government, or to perpetrators of fraud. Which entity – government or crooks – is more likely to make use of that money in a truly stimulatory fashion? It boils down to the old argument between Keynes and Hayak, of course. In the interest of both brevity and civility, DrRich declines to take up this argument at the present moment. Still and all, it is indeed a point for consideration.
But the government – and any healthcare payer – benefits immediately from this new program, even before the elderly person dies.
A major strategy in cutting the cost of healthcare – THE major strategy – must always be directed toward controlling the behavior of PCPs. This strategy, for instance, fully explains the massive tangle of uninterpretable rules and regulations which the PCP must painstakingly navigate today, the violation of any one of which is now a federal crime punishable by massive fines and imprisonment. Another tactic for controlling the PCP’s behavior is to severely constrain their face-time with patients, and to tightly regulate what must occur during these now-brief doctor-patient encounters.
Accordingly, during the 7.5 minutes allotted for each patient visit, the PCP must complete a 10-to-15-point checklist of required activities that fall under the rubric of “Pay for Performance.” Such checklists are designed, among other things, to keep the PCP and patient from straying off to address medical questions which do not appear on approved lists, and which might lead to unfortunate medical expenditures.
From the government’s standpoint, adding yet another obligation to the PCP’s critical checklist – an obligation which is so obviously beneficial to our elderly citizens, and which after all takes only three minutes to complete (leaving a full 4.5 minutes for actual medical issues) – is a very useful thing. And furthermore, it is the right thing. Anyone objecting to PCPs being directed to screen for financial abuse in their elderly patients immediately reveals themselves to be completely heartless and unfeeling and, likely, a Republican.
The PCPs, of course, are the only losers here. They are being asked to add yet another impossible task to their already-impossible list of jobs. Furthermore, as we have seen, once some outside body declares that it is the PCPs job to accomplish some impossible new task (such as assuring that all of their patients actually quit smoking), then our friends in the legal profession can immediately begin suing PCPs who fail to accomplish it.
So now the adult children of neglected elderly parents, finding that their inheritance has been frittered away because someone talked Pap-Pap into having a new roof installed on his house every year, will have somewhere to go to recover their damages.
If, as has been DrRich’s contention, the ultimate goal is to render primary care medicine so very odious, demeaning, exasperating and dangerous as to become a completely untenable proposition for any self-respecting American physician, so that by default the role of PCP will have to be filled with lower-level professionals who presumably will be more accepting of central directives, happier with checklists, and more comfortable with time-clocks than most doctors ever could be, then this new initiative is more than just a good idea. It is truly inspired.
DrRich is delighted to note that a very good and longtime friend and former colleague has been named as one of the HealthLeaders 20 for 2010 – that is, as one of 20 people, chosen by HealthLeaders Media, who are changing healthcare for the better.
DrRich has known this man for nearly two decades, and from the very beginning he has insisted his real name is Joe Smith. So let’s go with that.
Joe’s recognition by HealthLeaders is very well deserved. Joe is chief medical and science officer of the West Wireless Health Institute in San Diego, a non-profit institution whose mission is to bring wireless technologies to the patient, technologies to diagnose, monitor and treat health conditions in the patient’s own home. Joe is uniquely qualified for this role, having earned a PhD in medical engineering and medical physics, an MD from Harvard (a place DrRich has never even been allowed to see), and having spent years practicing medicine as a (particularly well known) cardiac electrophysiologist. (Electrophysiology, as regular readers will know, is widely recognized as the geekiest of medical specialties.)
For what it’s worth, DrRich considers Joe to be one of the most honest, most ethical physicians he has ever known, one who will always place the welfare of patients ahead of his own treasure and his own career. DrRich has seen him do it.
Significantly, one of Joe’s chief goals at West Wireless is to use advanced biosensors, attached to wireless communication, to lower the cost of healthcare. This can be done in at least two ways. First, by using wireless healthcare to keep patients healthy longer, and thus reduce hospitalizations and other expensive healthcare services; and second, by making at least some of these technologies available as consumer products, used by patients as they see fit for their own benefit, so they become part of the general economy (like toothbrushes and televisions).
DrRich is particularly pleased that Joe’s efforts are being recognized as worthy, since DrRich himself has devoted much of his professional effort to biosensors and wireless healthcare for the past 10 years. Indeed, at one point he had the pleasure of working together with Joe Smith in this area.
The Top 20 healthcare leaders to which Joe has been named is an eclectic group. It includes John Goodman, another of DrRich’s heroes, as well as a couple of people readers of this blog would recognize as individuals whom DrRich would not consider as “changing healthcare for the better.”
In any case, please go read the HealthLeaders write-up of Joe Smith and his cutting-edge work at West Wireless. Congratulations, Joe!